Early ART for HIV is advised

August 17, 2012
Formulary staff

Antiretroviral therapy should be offered to all patients as soon as possible, regardless of CD4 cell count, according to new recommendations offered during the AIDS 2012: XIX International AIDS Conference.

Antiretroviral therapy (ART) should be offered to all patients as soon as possible, regardless of CD4 cell count, according to new recommendations offered during the AIDS 2012: XIX International AIDS Conference. The new guidelines, published online July 25 in the Journal of the American Medical Association, include recommendations on changes in therapeutic options and modifications in the timing, and choice of ART in the setting of opportunistic illnesses.

Melanie Thompson, MD, of the AIDS Research Consortium of Atlanta, headed the panel for developing the 2012 Recommendations of the International Antiviral Society–USA Panel (IAS-USA). Dr Thompson and colleagues systematically reviewed the literature on treatment outcomes over the past 2 years to assess guidelines and provide current recommendations that take into consideration improvements in the potency, tolerability, simplicity, and availability of ART.

“This revision of the International Antiviral (formerly AIDS) Society–USA (IAS-USA) guidelines reflects new data informing consideration of when to initiate ART, new options for initial and subsequent therapy, ART management in the setting of special conditions, and new approaches to monitoring treatment success and quality,” Dr Thompson and colleagues wrote. 

According to Dr Thompson and the panel, evidence indicates that ART reduces the likelihood of HIV transmission while providing clinical benefit to treated individuals. Therapy can be offered, regardless of CD4 cell count as long as a patient is ready and willing to adhere to the regimen.

The initial recommended regimens include 2 nucleoside reverse transcriptase inhibitors (tenofovir/emtricitabine or abacavir/lamivudine) plus a nonnucleoside reverse transcriptase inhibitor (efavirenz), a ritonavir-boosted protease inhibitor (atazanavir or darunavir), or an integrase strand transfer inhibitor (raltegravir).

When prescribing, physicians have to take into consideration convenience for the patient, potential toxicities and the ability to continuously suppress HIV. Interactions among drugs also are a growing challenge, the authors note.

The strength of the recommendation increases as CD4 cell count decreases and in the presence of certain conditions, such as pregnancy, chronic hepatitis B virus (HBV) coinfection, hepatitis C virus (HCV) coinfection, age older than 60 years, and HIV-associated nephropathy. They offer alternatives for patients with or at risk of these concurrent conditions and add that patients should be monitored for their CD4 cell count, as well as for HIV-1 RNA levels, ART adherence, HIV drug resistance, and quality-of-care indicators.

The authors warn that treatment should not be interrupted outside of clinical trials, surgery, severe illness, or serious drug toxicity. Reasons the authors offer for regimen switching include virologic, immunologic, or clinical failure and drug toxicity or intolerance; however, treatment failure should be confirmed and addressed immediately and all potential contributory factors should be considered to prevent further evolution of drug resistance.

“The aim of therapy continues to be maximal, lifelong, and continuous suppression of HIV replication to prevent emergence of resistance, facilitate optimal immune recovery, and improve health,” the authors wrote.

“Although it is crucial to intensify efforts to find a cure for persons who are already infected and an effective vaccine for those who are not, many of the tools needed to control the HIV/AIDS pandemic are already at hand. Critical components of the toolkit to eradicate AIDS include expanded HIV testing, increased focus on engagement in HIV care, early and persistent access to ART, and attention to improving ART adherence. These must occur in the context of strategies to address social determinants of health, including the elimination of stigma and discrimination.”